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Extensive literature shows no significant differences in therapeutic outcomes between therapeutic approaches, but yet, these approaches differ to varying degrees in regards to values, techniques and emphasis on structure. This then poses an equivalence paradox with clearly non-equivalent techniques. The explanation for this commonality in therapeutic outcome between therapeutic approaches is the client-therapist relationship also known as the therapeutic alliance. The therapeutic alliance is a more encompassing term for the underlying interpersonal interactions and the collaborative nature of the partnership between a therapist and a client.
Meta analytic research studies show that the therapeutic relationship counts for . 21 in effect size, while in combinations with technical focus, the effect size is . 76. While not equally as effective as technique alone with an effect size of . 55, it is significant in its contributions to therapeutic outcome and has been worth the focus on how it develops over time and the subsequent development of a generic structure to establish and maintain across all theoretical approaches.
This essay will aim to explore this partnership and the necessary steps or requirements on the part of the therapist in order to establish it and the ways client preferences and goals are incorporated into treatment, in other words, structure required for the establishment and maintenance of the relationship as there is research evidence to support the establishment of this alliance early for stronger therapeutic outcome.
Generally, work with clients usually have a preparatory phase: a first phone call perhaps, and introduction on both parts to the tasks and goals ahead.
A beginning phase that involves the face-to-face meet up, initial greeting an outline of the therapist’s agenda, contracting, negotiating and setting and summary of goals. A middle phase: the therapist is concerned with facilitating learning and change congruent with therapeutic goals and assumptions about change. The ending phase also involves process goals in order to seek resolution of client issues, consolidate learning and change and evaluate therapeutic outcome.
There’s evidence to show that therapeutic alliance needs to be formed within the first three sessions for a good therapeutic outcome. Regardless of the therapeutic approach, there is evidence that certain generic skills are important and required for the establishment of a structure within therapeutic alliance. These generic skills include basic communication skills, but also more complex skills which the therapist needs.
They can be learnt and practiced as techniques but the therapeutic use of them with the client depends not only on the communication skill but on the attitude and intention of the therapist, an inside energy of sorts, that comes from commitment to understand the person from their frame of reference and the therapists internal supervision, awareness and self-review. The following macro and micro skills ensure the therapist emphases the importance of inner work alongside their practice. 1) Making Psychological contact
This is an intangible personal process that changes from moment to moment, a psychological exchange of energy between human beings. It is dependent on the skills, experience, attitudes and emotions that each brings to the situation and it presents itself on a spectrum. It ranges from clients who make no contact at all to those who invade the therapist’s personal space and on the other side, the therapist’s ability to make contact could be influenced by how they perceive new clients and other factors such as culture, class, race, gender, age and sexual orientation.
The therapist’s experience of initial interpersonal contact can be developed by self-reflection. Impartial witnessing: The observation of inner processes without judgement. Awareness of how others experience the therapist’s psychological contact e. g. Is it warm or cool, intrusive or distant etc? And finally, skills of greeting appropriately and starting the interaction with particular adjustments made after attention is paid to and sensitivity of culture, age, gender etc. 2) Effecting Intake and Assessment
In an interview or a formal assessment, specific skills are needed. They include: Asking for information: It is imperative that the client is made to understand the purpose of the questions and what will happen with the records. Purpose stating: What the therapist wants to happen and must happen. This helps to set the scene of openness to clients so that they know the therapist’s intentions or purpose and also to experience the therapist as congruent.
Preference stating: What the therapist would like to happen with an element of choice for the client. Knowing when to say “no” to a client and knowing how to communicate this congruently, respectfully and empathically. 3) Introducing tape recording This is something therapist’s approach with trepidation and technical skill and appropriate equipment is required to execute. The therapist requires confidence and conviction to obtain permission from the client and it needs to be part of the initial contract. 4) Contracting and clarifying therapy
Negotiating a contract with a client requires particularly the multiple skills of active listening, paraphrasing, reflecting feelings, summarizing, asking questions, purpose and preference stating, a balance between assertion and flexibility. 5) Beginning to build a relationship The ability to communicate empathic understanding of the client, to show unconditional respect, and to be perceived as congruent, requires inner and outer, receptive and responding skills. The client needs to hear that the therapist understands him from his point of view, accepting and not judging him, and is openly present for him and genuine in the role.
This openness conveyed by the therapist may vary with the orientation: Skills required to communicate this are: 1) Attention giving: The non-verbal show of accessibility, receptivity and presence which are all influenced by an inner attitude dependent on the awareness and sensitivity of the therapist. 2) Observing: Knowing what non-verbal and verbal cues to look out for. For example; posture, facial expression, tone and volume of voice, responsiveness etc. These clues are sought to begin to understand the client’s internal frame of reference.
Also, the therapist needs to scan their own body for clues and observe how the client makes them feel. 3) Listening and Hearing. The former is merely the inner sensory activity that involves picking up sounds while the latter is the same inner sensory activity aligned with attention giving. When clients feel really listened to, they are encouraged to talk and reveal themselves. Accurate listening can help clients to increase self-awareness and reduce defensiveness and direct focus towards their own behaviour. It provides psychological space and support for client’s self-exploration.
The use of a combination of the above skills to focus the therapist and client at appropriate points in the interaction. It can be used as a check for understanding, pulling together thoughts, bridge to help client move on, return to something significant and to structure the interaction if the therapist or the client is getting lost. 5) Responding or facilitating skills: Also known as active listening skills. These demonstrate and communicate empathy and acceptance and facilitate exploration. They are sometimes referred to as first level empathy, distinguishing them from deeper empathy.
The latter is used when there is deeper understanding of the client’s inner world. Using advanced empathy too soon, exposes a risk of inaccuracy and poses too much of a challenge for the client. First level empathy consists of paraphrasing and reflecting feelings. Paraphrasing is picking up the meaning of the client’s words and having and extensive vocabulary to put it back to him reflecting accurately the feeling and meaning in a tentative way to check understanding. It is not parroting and using jargon or over technical terms.
Done well, it enables clients to hear and understand themselves afresh. Reflecting feelings is identifying what the client is feeling often mainly from non-verbals like tone of voice, bodily expression and therapist’s own bodily resonance. Therapist’s need to be sensitive to different cultural subtleties as inaccurate reflections may neutralize the intensity of the client’s feelings. All these skills are the beginning blocks for building a relationship and for helping clients explore what they want from a therapist and therapy. In the main they are supportive skills.
Skills which continue to build the relationship and develop the interaction will be considered next. These skills are challenging, both for the client and therapist. Development and maintenance of the therapeutic relationship: Moving the client forward As mentioned above, the skills discussed so far can be considered as supportive – helping clients feel safe enough to begin to explore themselves and their situation. To move on in the relationship and the interaction requires skills which will challenge the client to explore further – to gain new perspective and new frameworks and see the world in a different way.
How the client will receive the challenge will depend on the relationship which has been built and how it is maintained and developed; all the supportive skills will still be needed, appropriately interspersed with the challenging ones. Inner skills: Challenging a client requires the inner skill of the therapist in examining their own feelings about challenging others. The therapist needs to know how comfortable they are with challenging a client. This skill is should be applied tentatively and timing is crucial.
A therapist needs to be able to gauge implicitly and explicitly when and how to challenge a client and which of these interactions are based on theories of counselling and psychotherapy. This skill really requires an inner awareness and careful attention to personal development is required. This is where tape recording and supervision are important in the review and identifications of values, beliefs, thoughts, feelings and sensations guiding the choices made. Outer skills: Responsible challenging requires well-practised communication skills.
Focusing. The therapist needs to help clients focus, if they are to move forward. Summarizing. As mentioned above, summarizing provides bridges, draws themes together and is used for keeping track. It is a useful skill that requires accurate listening, ability to filter relevant thoughts and feelings and ability to communicate them clearly. Both summarising and focusing provide challenge to clients Concrete examples. Sometimes it can be useful to ask clients for more specific thoughts, experiences and feelings. Communicating deeper empathy.
The ability to pick up the real meaning behind the words, thoughts and feelings of the client which are buried, out of reach or implied and which may come to the therapist as a hunch. The skill is to put it into appropriate words when the timing is right. Challenging. Gently confronting clients to change their perspective, see a bigger picture, recognize strengths they are not using, note discrepancies between verbal and non-verbal behaviour or identify behaviour that is destructive to them and others. Self-disclosure.
Here there are two types; the therapist disclosing past experience or the disclosure of thoughts and feelings about the client’s thoughts or experiences. There are advantages and disadvantages to this. Timing and discrimination of content disclosed is important. It could help as a model for the clients and help build the relationship or it may be perceived by the client as maladjustment and hence reduce confidence or the increased intimacy may be threatening to them. It is unhelpful at the beginning stages of therapy as the therapist should be concentrating on staying with the client’s experience.
Disclosure needs a sufficiently secure relationship and should be used selectively at the later stages of therapy. Immediacy. Discussing directly and openly what is happening between therapist and client. It involves awareness of what’s going on inside the therapist and what is imagined as going on within the client and what is happening between the two. It is quite complex and challenging to do well, but when executed properly provides client with insight as to how their behaviours affect others.
It involves competence in support skills as well as self-involving statements. It requires assertion and is very helpful to build or repair a therapeutic relationship, identify issues with class, age, gender, race, sexuality etc and in psychoanalysis and psychodynamic practice, identify transference and countertransference. All the skills so far require a lot of practice with feedback for development and lead to the final section. Monitoring self within the therapeutic process, evaluation and development of own work.
This requires all the previous skills as well as the additional self-management skills which are: developing a caring acceptance of self, impartially witnessing of internal processes, identifying and using resources to meets learning, emotional, physical needs, ongoing identification and checking of belief and theories, planning ongoing training and personal development, reflecting, review of recordings and supervision, reviewing with clients and asking for feedback from clients Summary Both supporting and challenging skills, regardless of theoretical approach are necessary for the establishment of structure within a therapeutic relationship.
This structure and framework is important in ensuring that therapists are mindful of what is required to provide a supportive base to establish trust and rapport and then in the later stages more challenging skill are utilized to provide the necessary challenge that is required to guide clients into awareness and positive change. Another possibly useful generic skill would be a termination skill to help the therapist during the end phases of therapy help the client consolidate learning and evaluate outcome and prepare for possible relapse prevention and management and finally, client autonomy.
Theoretical considerations There is no denying that the generic skills discussed above have built around and extended from the conditions identified by Carl Rogers in person centred therapy, to reiterate, they would be the maintenance of an attitude of acceptance or unconditional positive regard, empathic understanding, as well as personal congruence or integration. Being a non-directive therapeutic approach that typically places emphasis on the above, supportive skills would be utilized mainly.
Challenge skills, less so, but on occasion, as onus is placed on the client directing the therapy. Cognitive behaviour therapy utilizes an active-directive collaborative style. In its very nature, it is quite structured. In reductionist terms, it occurs in the following four stages: the assessment, cognitive, behavioural and learning stages. The therapeutic alliance needs to occur in the assessment stage, usually in the first session because quite rapidly after, from the cognitive stage, negative automatic thoughts are identified and challenged.
This means, supportive skills and challenge skills are introduced quite rapidly and interwoven up till the learning stage and termination. In Psychoanalytic and psychodynamic approaches, a distinction is made between the real relationship, transference and counter transference and a working alliance. The real relationship would be akin to the therapeutic relationship as defined earlier and would only be encountered after transference and counter transference because they are considered to be more of a contamination to the real relationship and would need to be worked through and resolved.
Meaning the therapist would take a more reticent stance, utilizing mostly support skills initially and challenge skills only during the working alliance, (the alignment of the client’s reasonable self or ego and the therapist’s analysing self or ego for the purpose of therapy) towards the later stages of therapy where interpretation of unconscious conflicts, defence mechanisms and resistances take place. Other considerations Having a framework is important in the development and establishment of rapport and therapeutic alliance but there are salient points to factor in.
The therapist needs to have a level of awareness of the similarities and differences between them and their prospective clients to avoid the traps of varying degrees of gender inequality, ageism, disability and social class discrimination, homophobia and other sexual orientation based discrimination, religion, spiritual, agnostic and atheist discrimination, and also, racial, cultural and ethnical discrimination. Regardless of how well a therapist conceptualizes how to establish therapeutic alliance, lack of knowledge and experience on these socio economic and socio cultural factors could prove counterproductive.
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